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Medical Documentation of Non-Accidental Trauma

Learn about the practical and legal aspects of medical documentation in non-accidental trauma.
Watch on YouTube

Released:

January 20, 2015

Audience:

Physicians, Social Workers

Learning Objectives
  • Recall documentation principles that are critical when airway, head, or neck findings raise concern for non‑accidental trauma

  • Explain how objective, timely documentation supports safe airway decision‑making and mandated abuse reporting in critically ill children

  • Apply neutral, descriptive documentation practices to airway‑related findings (e.g., facial bruising, oral injuries, altered mental status)

  • Analyze how documentation errors or omissions can compromise airway safety, multidisciplinary care, and legal defensibility

  • Evaluate clinician responsibilities for reporting, photographing, and recording findings when airway management occurs in suspected abuse cases

Author(s)

Kelly Haynes, ADN, JD

Risk Manager | Dana Farber Cancer Institute


Traci Wolbrink, MD, MPH

Co-Director, OPENPediatrics; Co-Director, Center for Educational Excellence and Innovation; Program Director, Pediatric Critical Care Medicine Fellowship; Senior Associate in Critical Care Medicine | Boston Children’s Hospital

Associate Professor of Anaesthesia | Harvard Medical School

Citation

Haynes K, Wolbrink TA. Medical Documentation of Non-Accidental Trauma. 1/2015. Online Video. OPENPediatrics. https://learn.openpediatrics.org/learn/course/internal/view/elearning/3054/medical-documentation-of-non-accidental-trauma.

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